Patient: Male, 68Final Diagnosis: Urinary bladder angiosarcomaSymptoms: —Medication: —Clinical Procedure: TURBTSpecialty: Diagnostics, LaboratoryObjective:Rare co-existance of disease or pathologyBackground:Angiosarcoma is a fatal and aggressive mesenchymal tumor. It occurs in skin, breast, and parenchymal organs. It rarely arises primarily in the urinary bladder. Only 13 cases of primary urinary bladder angiosarcoma have been reported in the English literature.Case Report:The patient was a 68-year-old man who presented to the Emergency Department with inability to void. Computed tomography of the abdomen and pelvis showed a urinary bladder mass. Surgical excision of the mass was performed. Pathological examination results were consistent with angiosarcoma. In addition to the unusual location of this tumor, the pathology was different from the previously reported cases in that this case was rich with osteoclast-like multinucleated giant cells.Conclusions:The pathological diagnosis of primary urinary bladder angiosarcoma is challenging. Histological patterns and immunophenotypes are variable. Here, we review all reported cases of primary urinary bladder angiosarcoma, highlight the clinical and morphological features of this malignant neoplasm, and report a unique case of primary urinary bladder angiosarcoma with osteoclast-like multinucleated giant cells.

Objectives: The goal of this project was to evaluate and improve the ordering, administration, documentation, and monitoring of enteral nutrition therapies within the inpatient setting in a Veteran's Health Administration system.Methods: An interdisciplinary team of clinicians reviewed the literature for best practices and revised the process for enteral nutrition support for hospitalized veterans. Interventions included training staff, revising workflows to include scanning patients and products, including enteral nutrition orders within the medication administration record (MAR), and using the existing bar code medication administration system for administration, documentation, and monitoring. Baseline and postprocess improvement outcomes over a year period were collected and analyzed for quality improvement opportunities.Results: Before process change, only 60% (33/55) of reviewed enteral nutrition orders were documented and 40% (22/55) were not documented in the intake flowsheet of the electronic health record. In the year after adding enteral nutrition therapies to the MAR and using bar code scanning, a total of 3807 enteral nutrition products were evaluated. One hundred percent of patients were bar code scanned, 3106/3807 (82%) products were documented as given, 447/3807 (12%) were documented as held (with comments), 12/ 3807 (<1%) were documented as missing/unavailable, and 242/3807 (6%) were documented as refused.Conclusions: Inclusion of enteral nutrition order sets on the MAR and using bar code scanning technology resulted in sustained improvements in safety, administration, and documentation of enteral therapies for hospitalized veterans.

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IntroductionAs the growing popularity of robotic assisted laparoscopic procedures for the treatment of renal cancer increases, there exists a variation in surgical technique among institutions and surgeons alike. One variation that exists in robotics is the anatomical placement of the camera port (medial versus lateral camera port placement). The purpose of this study is to evaluate surgical complications and outcomes in comparison to site of camera port placement during nephron-sparing surgery in an academic setting. MethodsOver a three-year period, outcomes for all robotic surgeries for renal cancer were examined. A total of 229 cases were discovered. Patient demographics and comorbidities were analyzed along with perioperative surgical data including location of camera port, surgery length, warm ischemia time, blood loss, pathological tumor margins, tumor size, length of stay and laboratory data. Outcomes134 patients had surgery performed with lateral camera port placement versus 95 patients with medial camera port placement. Operative time was significantly lower with an average operative time of 165.8 minutes for the lateral group versus 209.1 minutes in the medial group (p <0. 0001). Warm ischemia time was also less in the lateral group with an average of 11 minutes versus 15.5 minutes for the medial group (p <0. 0001). Blood loss was less in the lateral camera port group with an average of 158.2mL (+/- 196.5mL) versus 248.6mL in the medial group (+/- 252.6) (p=0.0040). Drain use, positive surgical margin rate, transfusion rate, conversion to radical nephrectomy, change in preoperative versus postoperative creatinine and glomerular filtration rate and length of hospital stay did not statistically differ.ConclusionLateral camera port placement is associated with decreased operative time and warm ischemia time in this series. There may be certain laparoscopic advantages through a better visualization of surgical anatomy, thus allowing for faster extirpation of renal lesions and decrease in surgical time. These advantages may result in better long-term renal function and decreased clinical sequela from chronic kidney disease.

IntroductionAs the growing popularity of robotic assisted laparoscopic procedures for the treatment of renal cancer increases, there exists a variation in surgical technique among institutions and surgeons alike. One variation that exists in robotics is the anatomical placement of the camera port (medial versus lateral camera port placement). The purpose of this study is to evaluate surgical complications and outcomes in comparison to site of camera port placement during nephron-sparing surgery in an academic setting. MethodsOver a three-year period, outcomes for all robotic surgeries for renal cancer were examined. A total of 229 cases were discovered. Patient demographics and comorbidities were analyzed along with perioperative surgical data including location of camera port, surgery length, warm ischemia time, blood loss, pathological tumor margins, tumor size, length of stay and laboratory data.Outcomes 134 patients had surgery performed with lateral camera port placement versus 95 patients with medial camera port placement. Operative time was signi cantly lower with an average operative time of 165.8 minutes for the lateral group versus 209.1 minutes in the medial group (p <0. 0001). Warm ischemia time was also less in the lateral group with an average of 11 minutes versus 15.5 minutes for the medial group (p <0. 0001). Blood loss was less in the lateral camera port group with an average of 158.2mL (+/-196.5mL) versus 248.6mL in the medial group (+/-252.6) (p=0.0040). Drain use, positive surgical margin rate, transfusion rate, conversion to radical nephrectomy, change in preoperative versus postoperative creatinine and glomerular ltration rate and length of hospital stay did not statistically differ. ConclusionLateral camera port placement is associated with decreased operative time and warm ischemia time in this series. There may be certain laparoscopic advantages through a better visualization of surgical anatomy, thus allowing for faster extirpation of renal lesions and decrease in surgical time. These advantages may result in better long-term renal function and decreased clinical sequela from chronic kidney disease.